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., f .�C,5- .APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 'HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE`ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4oe /V. wlyoS� Cit Lot Size PM I Owner's Name-R'V15 A5m4A) Address Liz lAl2 PI1� L,y�f Phone ��/& Contractor Addres4Z_ Z f:7rC.t)�-Q License No. Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM DESTRUCTION ❑ PUMP INSTALLATION Q SYST EPAIR D ':rte OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE ..� i DISPOSAL FLD. PROP. LINE OUNDATION. RICU RE WELL_. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL/!"' PR'OBLE EA CONSTRUCTION.SPECIFICATIONS 1 y ❑ Industrial ❑ Open Bottom t ❑ 'M eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private '❑ Gravel Pack racy Type of Casing Specifications ' M Public 1� Other O'Delta Depth of Grout Seal Type of Grout J I Irrigation _..Approx. Dep t I Eastern urface Seal Installed by _ Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 _ r TYPE OF SEPTIC WORK: NEW INSTALLATION I k REPAIR/ADDITION t I DESTRUCTION' fNo septic system permitted if public sewer is 09 3 available within 200 feet.) Installation will serve: Residence_ [Commercial_ Other Number of living units: Number of bedrooms _ a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments ~� PKG. TREATMENT PLT. [I i P Method of Disposal i Distance to nearest: Well Foundation Property Line ti LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED (D Distance to nearest: Well Foundation Property_Line SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ t...__.. I hereby certify that I have prepared this application and that the work will-be—'done in accordance with San Joaquin county ordinance's, state laws, and rules and regulations of the San Joaquin local Health District.,.:,- .'_v Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to.workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work fo'r which this permit is.issued, I shall employ persons subject to worKman'S compensa- tion laws of California." The applicant st_call for all requir inspections. Complete drawing on reverse side. r Signed X`- �( - �d�lJ'1.f.�--- Title: _= Date: - R 5PA ONLY- Application Accepted b Date Area Pit or Grout In ctio Date Final Inspection by Date Additional Co ments: ) J-2-7�2 CJ 3 i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 01 i INFO 00 FEE AMOUNT DUE AMOUNT EAMOUNT REMITTED CIC RECEIVED 8Y DATEc'� PERMIT NO. + EH 13-24 MEV.1/H 5) / EH 14-28 V�� l